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Cleft Lip & Palate

Doctorate of Clinical Dentistry in Orthodontics (Notes) Orthodontic Dept. University of Glasgow

By:
Mohammed Almuzian 2012

Cleft lip and palate


Definition Incomplete fusion of hard and /or soft tissue structures of the lip and palate.

INCIDENCE

A. B.

Genetic risks One affected parent, risk of the first child 2% One affected child, risk of next child with is (4%). Two affected parents, risk of first child 60% Prevalence in the UK population UCLP CP BCLP CL Others e.g. submucous cleft 40% 30% 10% 10% 10%

C. 1. 2.

CLP Incidence of unilateral CL(P) varies with race: In UK 1 in every 1000 live births In Caucasians it is about 1 in every 750 live births (Mitchell, 2000).
Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 1

3. 4. 5. D.

In oriental populations is around 1 in very 600 live births. In Negros is around 1 in every 2000 live birth. Left side is more affected than the right side (2:1). CP: Prevalence around 1 case in every 2000 live births. 55% Associated with syndromes such as Down, Treacher-Collin, PierreRobin Syndromes.

E.

Gender distribution: CLP has greater incidence in males. There is a male predominance of submucus clefts. CP the incidence is higher in females overall (4:1). There is equal gender incidence of isolated soft palate clefts

Syndromic and non-Syndromic clefting 15% of cleft children have additional malformations and there is a tendency for children with bilateral clefts to have additional malformations
1.

Van der Woude. Incidence of approx. 1:28,000 (2% of cleft cases). Autosomal dominant. Lower lip pits +/or CL/P or CPO and hypodontia. No other anomalies.

2. 3.

Pierre Robin sequence. Triad of cleft palate, micrognathia, macroglossia Treacher Collins

Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012

Embryology of clefts of the lip and palate

Lip development
Facial development begins at 4-6 weeks 5 facial prominences. Frontonasal process (unpaired), Paired maxillary process and Paired mandibular process Nasal placodes on the surface of the FNP begins to invaginate at 5 weeks, ridges around pits are the medial and lateral nasal process (also partly made up of the maxillary process) The two mandibular processes are the first to unite and give rise to the lower lip, lower portion of the cheeks and other mandibular structures. Medial nasal processes develop into the philtrum, primary palate and the four maxillary incisor teeth and their surrounding alveolar bone. The maxillary processes form the remainder of the upper lip, the secondary palate and the upper portion of the cheeks. The lateral nasal process on each side unites to form the ala of the nose.

Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012

Abnormal lip Development Defective fusion at any of the sites highlighted in the above figures may result in a facial cleft.
1. 2. 3. 4. 5.

Cleft mandible Lateral facial cleft Oblique facial cleft Cleft Lip (Unilateral or Bilateral) Median cleft

Development of the palate


1 palate is made up of the medial nasal process. It contains the first four teeth and contributes the philtrum of the upper lip. 2 palate apparent at 6 weeks as inferiorly lying outgrowths from the maxillary process, lying lateral to the tongue. At 8 weeks shelf elevation begins .
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Theories of palatal shelf elevation. (Ferguson 1981)

1. 2. 3. 4. 5.

Extrinsic Tongue movement, increased mandibular prominence, lifting of the head relative to the body, straightening of the cranial base, increased height of the oronasal cavity. Intrinsic

1. Osmotic pressure, 2. Contraction (muscle/non-muscle, both have been proposed), 3. cellular reorganisation (increased density of epithelial/mesenchymal cells on the palatal side of the shelf causing rotation), 4. Vascular erectile force.

Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012

Following elevation, further growth brings the medial edge of each shelf into close contact. At this stage, mesenchyme from each shelf is still separated by an epithelial seam of medial edge epithelium.

Three mechanisms have been proposed to explain medial edge epithelium breakdown, apoptosis (programmed cell death), epithelial to mesenchymal transformation, and migration of epithelium to the oral and nasal compartments.

Regardless of the mechanism, breakdown of the epithelial seam results in mesenchymal continuity and palatal fusion. As well as fusion between secondary palatal shelves, an important step during palatogenesis is fusion of the primary palate to the secondary palate.

Abnormal palate Development


Clefts form when there is failure of process growth or fusion, this is due to: 1. Primary defects leading to cleft palate include:

Failure of shelf elevation; Failure of shelf growth ; Failure of shelf fusion. 2. Secondary defects leading to cleft palate include:

Growth disturbances in craniofacial structures Mechanical obstruction of palatal .

AETIOLOGY In normal development, fusions of the embryological processes that comprise the upper lip appear around 6 W.I.U life while fusion to form the secondary palate occur around 8 W.I.U life. Any disruption affecting the timing at which the fusion occurs will increase the incidence of cleft.

Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012

Bixler (1981) divided clefts into 3 aetiological domains


A. B.

Syndromic. Including chromosomal and environmental aetiologies. Familial or hereditary. A gene coding for TGF has been implicated. These encode a variety of different proteins include (FGF), MSX1 and MSX2

C.

Sporadically or Isolated or non-Familial. The proband is the first person in a pedigree with the defect. Most commonly:

Drugs like Steroids, Anticonvulsant drugs Infection like CMV, Rubella Smoking Alcohol Endocrine like Diabetes Deficiency of vitamin supplements such as deficiency in folic acids Trauma. Radiation. Maternal hypoxia

CLASSIFICATIONS

Descriptive method
This is most commonly used nowadays.
A.

Cleft lip Unilateral or bilateral Notched lip


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B. C.

Incomplete cleft lip Complete cleft lip Cleft alveolus (primary palate) Cleft palate Cleft uvula Soft palate only Submucous cleft Complete Incomplete

Symbolic method using the stripped Y.Kernahan 1971

LAHSHAL classification developed by Kriens 1989


L lip A alveolus H hard palate S soft palate UPPER CASE FOR COMPLETE CLEFT

Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012

lower case for incomplete cleft

Preventive treatment

Hartridge et al 1999 in a review investigating the role of pre-conceptional folic acid supplementation concluded that 0.4 mgs of folic acid from pre-conception to the 12 week of pregnancy ( 4mgs for mothers with cleft children) although not proved conclusively can have significant protective effects.

CSAG Report (Clinical Standards Advisory Group) by Shaw 1995 Professionals in the field of cleft work expressed concern regarding the quality of treatment outcome for patients with cleft lip and palate in the UK. In 1995 the Department of Health in the UK charged the Clinical Standards Advisory Group to investigate the quality of care within the UK. All children in the UK with a unilateral complete cleft lip and palate aged 5 or 12 years of age in 1996-1997 were examined. Their speech, hearing, appearance, dental malocclusion, dental health, quality of bone graft and skeletal base relationships were examined. Cleft care was provided in 57 centres. The study found that the average result in all these areas was poor. Children from the UK centres were more likely to suffer mid-face retrusion and poor dental relationships than three of the European centres. Fewer than 60% of children in the UK had a successful bone graft in comparison with 97% from one of the other European centres. It was therefore clear that some patients were not receiving optimal care in the UK.
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The CSAG report made several recommendations, including:


I. II. III. IV. V.

Centres should be limited to 8-15 in the UK. England and Wales, 10 centres Northern Ireland operates as a single centre Scotland operates as one single centre known as CLEFTSiS Each centre should provide a full range of cleft care. Nationwide database. Results should be regularly audited. Training should be provided for specialists in cleft care in high volume centres only.

VI.

Each clinical team consists of specialist orthodontists, surgeons, speech and language therapists, specialist nurses, geneticists, paediatricians, ENT specialists, anaesthetists and psychologists. In addition they have support staff responsible for data collection, audit documentation and photography.

METHOD OF ASSESSMENT

Methods of Assessment
Record taking recommended at 5,10,15,20 years (Lee et al., 1993) Lateral views Posteroanterior views Study models Photographs

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Index of 5-year old children (Attack et al., 1997):

Index for dental relationships of 5 year old patients born with unilateral cleft lip and palate.

It divided the cases into 5 categories to be able to compare treatment outcomes earlier and before surgical procedures and orthodontic treatment.
Grading

1. Grade I

Positive overjet average inclined or retroclined incisors No crossbites No openbites Good maxillary arch shape and palatal vault anatomy. Excellent outcomes

2. Grade 2

Positive overjet average inclined or proclined incisors Unilateral rossbite/crossbite tendency Open bite tendency around cleft site. Good outcomes

3. Grade 3

Edge-to-edge bite average inclined or proclined incisors; OR reverse overjet with retroclined incisors

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Unilateral crossbite Open bite tendency around cleft site Fair outcomes

4. Grade 4

Reverse overjet average inclined or proclined incisors Unilateral crossbite, bilateral crossbite tendency Open bite tendency around cleft site . Poor outcomes

5. Grade 5

Reverse overjet proclined incisors Very Poor Bilateral crossbite maxillary arch form and palatal vault anatomy Poor outcomes

GOSLON index (Great Ormond Street , London and Oslo Net) Yardstick (Mars et al., 1987)

It is a record of 10 year old patients To evaluate and compare the results of different approaches to the early management of the child with a unilateral cleft lip and palate of children in the early permanent dentition.

It represents the severity of malocclusion and the difficulty of correcting it.

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This depend on
I.

Anteroposterior Assessment of labial segements

The overjet is examined first. If there is a reverse overjet of 3 to 5 mm, this indicates that the case might belong to group 3.

However, if there is already dentoalveolar compensation a higher category should be considered.

The anteroposterior relationships of the buccal segments are not of importance in determining the grouping of a case.

II.

Vertical Assessment

It help in modification of the provisional category in borderline cases. Deep bite is favourable and AOB is unfavourable
III.

Transverse Assessment

It indicate a modification of the provisional category in borderline cases

Ranking of GOLSON index


1. Groups 1 and 2 have occlusions that require either straightforward orthodontic treatment or none at all. 2. Group 3 require complex orthodontic treatment to correct the Class III malocclusion but a good result can be anticipated. 3. Group 4 are at the limits of orthodontic treatment , and if facial growth is unfavorable, orthognathic surgery will be required. 4. Cases in group 5 require orthognathic surgery .

Bergland index for secondary ABG


Take periapical x-ray and assess the bone formation at interseptal area around the canine to assess bone formation Bergland (1986).

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1. 2. 3. 4.

Grade I: inter-alveolar bone at normal height Grade II: inter-alveolar bone of normal height Grade III: inter-alveolar bone less than of normal height Grade IV: no bone at inter-alveolar area. Failed outcomes.

Kindelan score
5.

After 4-6 months of ABG, take anterior occlusal radiograph and assess the success using Kindelan score 1997.

1. 2. 3. 4.

The degree of bony fill in the cleft area was assessed using a 4-point scale: Grade 1 > 75% bony fill; Grade 2 50-75% bony fill; Grade 3 < 50% bony fill; Grade 4 no complete bony bridge.

Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012

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Problems Associated with Cleft Lip and Palate I. General difficulties


1. 2. 3.

Feeding speech hearing (which inturn can effect speech development) and middle ear

infections
4.

psychological problems

II.

Dental disturbances in both repaired and unrepaired cleft cases


1. Hypodontia , 28% of UCLP and 60% BLCP 2. Supernumeraries 3. Delayed eruption of teeth on cleft side 4. Increased incidence of impacted upper first molar in non-cleft side (4x non-clefts individuals) (Bjerklin et al., 1993) 5. Hypoplasia 6. Microdontia

The above due to:

Disturbtion of the development of the dental lamina which produce tooth germs. In the patient with a cleft this process is disturbed and result in dental problems.

Msx1 genes mutation.

III.

Skeletal Features of unrepaired cleft lip and palate


It is called Embryological defects
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1. Cleft Lip only, maxillary arch development is generally normal. 2. Clefts in to the alveolus (incomplete) only with or without lip, Increased incidence of cross bites (19%) 3. Complete bilateral, Premaxilla is anteriorly displaced beyond the tip of the nasal septum. The lateral segments may have collapsed medially producing bilateral crossbites. 4. Complete unilateral, Major segment is rotated outward so the incisor area appears prominent, the lesser (lateral) segment is more variable and may be rotated outwards producing a wide cleft or there may be inward displacement and segment overlap. 5. Isolated clefts of the palate, Excessive inter-tuberosity width may be observed. 6. mandibular growth reduced 7. Increase MMP angle, Possibly due to disrupted nasal respiration, oral respiration and a mouth open posture, allowing buccal segments to overerupt.

IV.

Skeletal Features of repaired cleft lip and palate . (Shaw 1990)


Embryological defects + Iatrogenic effect of surgery

Iatrogenic effect of surgery


1. Lip repair. Minimal effect on facial growth,. 2. Transverse disturbances. Scar tissue in the palate leads to a tendency for buccal cross bites in the 1 and 2 dentitions. 3. AP disturbances. Palatal scar tissue around the tuberosity region hinders maxillary translation.. 4. Vertical disturbances.
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An in LFH is often found. Possibly due to disrupted nasal respiration, oral respiration and a mouth open posture, allowing buccal segments to over-erupt.

A in LFH in severe maxillary retrusion.

Ideal Cleft palate Team


1. Cleft nurse 2. Plastic surgeon 3. Orthodontist 4. Maxillofacial surgeon 5. ENT surgeon 6. Speech therapist 7. Audiologist 8. Pediatrician 9. Psychologist

Summary of the whole Treatment


In red are the roles of the orthodontist and GDP

Prenatal

Ultrasound assessment, 70% of the cases are detected on ultrasound scan at 16-18 weeks

At birth

Parent counselling Feeding

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Pre-surgical orthopaedic appliance 3-5 months1. Primary surgical lip repair 2. Nasal repair 3. primary alveolar bone grafting (old regiem) 1 year 1. Palate repair. 2. Preventive dentistry/advice 2-6 years 1. Revision of lip repair 2. Pharyngoplasty 3. tympanoplasty or grommet, Lees records Index Assessment 4. interceptive orthodontic to: correct X bite Align the maxillary dentition (usually using fixed appliances) in the growing child if the appearance causes the child distress or the irregular teeth are traumatizing soft tissues 5. Cleft orthodontists can be asked to provide obturators to assist with speech prior to closure of any residual fistulae at the time of alveolar bone grafting 8-10 years Lees records GOSOLN Index Assessment Maxillary expansion prior to bone grafting, extract
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supernumerary teeth, bone grafting 1. OHI and optimal oral health 12-15 Lees records Index Assessment 1. Definitive alignment of the maxillary and mandibular teeth using fixed appliances 2. Reverse facial mask 17-20 Lees records Index Assessment 1. Orthognathic surgery 2. Decompensation and alignment for orthognathic surgery using fixed appliances 3. For patients with velo-pharyngeal dysfunction, the poorly functioning soft palate is raised with a palatal lift appliance and the velo-pharyngeal space obturated to reduce hypernasal speech, which assists the Speech and Language Therapist in cases that are otherwise untreatable by language therapy alone with/without surgery. 4. Electropalatography is a relatively new technique where patients are provided with an upper removable orthodontic appliance incorporating numerous electrodes. When attached to a PC, the patient can visualise tongue to hard palate contact on various sounds and the Speech and Language Therapist can direct therapy sessions using this technique. Indeed portable EPG hardware is now available
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such that the patient can practice tongue positioning at home.

Prenatal age
Parent counselling: Parents are usually in a shock after birth, therefore a counselling is important to reassure them and facilitate the development of a bond between the mother and the child. 70% of the cases are detected on ultrasound scan at 16-18 weeks when looking for it. Cleft Lip and Palate Association (CLAPA) provide support for the parents.

At Birth
Feeding: 1. Orthodontist should give counselling and advice on feeding. 2. Acrylic plates are no longer used nowadays. 3. However, soft feeding bottles with modified teats which help to direct the flow of the milk into the mouth are helpful. 4. Some babies are fed by nasogastric tube. One of the most common reasons for a cleft baby being fed this way is due to Pierre Robin sequence. Many of these babies have severe airway problems and due to the smallness of the lower jaw, the tongue remains in a very posterior position, making oral feeding impossible for weeks or even months. Pre-surgical orthopaedics: 1. Pioneered by McNeil. 2. It is usually carried out immediately after birth.
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3. The aims of this are: a. Passive obturating plates that Assist feeding b. Extra oral strapping aid in Positioning of the segments to help surgical closure of the lip specially in severe arch distortion c. active obturating plates In unilateral clefts reduces displacement of the greater segment and maintain the position of the lesser segment. In bilateral clefts to move the lateral segments outwards while the prolabium is moved palatally and rotated downwards. Reduction of premaxillary protrusion in bilateral clefts. Treatment comprises an intra oral appliance carrying an active component to separate the lateral segments. Elastic strapping across the prolabium (upper lip) is used to restrain the premaxillary growth. d. Stabilizer: Help maintain the transverse dimensions after the primary surgery (retention period about 3 months).

Recent evidences Shaw 2004 and Dutch-cleft study by Anderson suggest that these devices offer no benefit to outcome either in terms of the surgery or feeding during this period.

Three Months of age


A. Lip Repair Millard technique (gives best scar) with McComb nasal correction Tennison technique (gives fuller lip)

Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012

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B. Nose Repair: alar cartilages may be repositioned at this time to increase symmetry and improve the appearance C. Alveolar Repair, primary alveolar bone grafting not recommended. However it depend on the use of vomerian flap to close the cleft D. Dental roles: continued advise on feeding, oral health

E. ENT: tympanoplasty, aspiration and grommets A cleft involving the posterior part of the palate and the soft palate will also involve the tensor palate muscles, which act on the Eustachian tube. This predispose to problems in the middle ear ventilation (glue ear). Therefore, it is important that the cleft patients ears should be examined at the time of lip surgery to ensure adequate middle ear drainage. About 98% of the cleft patients will have otitis media (Grant et al., 1988) and will need tympanoplasty, aspiration and grommets (ventilation tubes inserted through the tympanic membrane under general anaesthetic.)

Six Months of age


A. Palatal Repair Soft palate repair 1. Furlow or Z-plasty 2. Intra-velar veolplasty: radical dissection and reorientation Hard Palate repair 1. V-Y closure technique 2. Von Langenbeck technique Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 22

3. Delair technique 4. Primary tongue flab technique

Some claim that it is better to delay the closure to 5-6 years to avoid scar occurrence and subsequent growth retardation. But in this case the defect should be closed with obtutator, so the speech is dramatically influenced.
B. Dental roles:

continued advise on feeding, oral health

C. Sometime Lip and soft palate repair undertaken at 6 months at one time D. Pharygoplasty:

In proportion of cases the repaired palate does not completely seal off the nasopharynx during speech and nasal escape of air may occur, resulting hypernasality.

Nasopharyngoplasty is undertaken at the same time as the primary palatal repair is performed.

However, it is preferable to carry this procedure at the age of 4-5 years.

Aetiological factors pf speech problems:1. 2. 3. 4. 5.

Velopharyngeal insufficiency, Hearing problems Dental and occlusal anomalies. Developmental learning disability. Psychosocial impact.

Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012

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2-5 Years of age


1. Lee records at 5 years stage 2. Assessment using the 5-year-old index introduced by Atack 1997 3. Interceptive Orthodontic treatment.

Elimination of anterior crossbites Identify potential problems such as supernumaries. If 15 and 25 are missing plan early loss of maxillary Es to allow spontaneous closure of 16 and 26. In deep bite case consider a bite plane to allow posterior tooth eruption. Plan loss of deciduous teeth around the cleft early to improve quality of mucosa prior to grafting
4. Dentist roles

diet analysis OHI use of fluoride restorative care 5. Speech and hearing assessment. Consideration for pharygoplasty and grommets. 6. Primary bone grafting is carried out within the first 2 years of life and is less popular than secondary bone grafting. Primary bone grafting is considered unfavorable and usually results in crossbite, malocclusion and malunion of the maxilla.

Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012

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7-10 years of age

1. Lees records 2. Goslon Yardstick (Mars 1987) . 3. Secondary alveolar bone grafting:

Alveolar bone grafting Introduced by Axhausen (1952). Technique popularised by Boyne and Sands (1972, 1976). Pre graft records. Occlusal, Study models and photos Orthodontic preparation for graft at approximately 8-11 years before the eruption of the maxillary canine (Bergland 1986), ideally when the canine root is to formed . One exception is, if the lateral incisor tooth is present, then earlier grafting may be considered.

The viability of the result depend in the presence of unerupted teeth otherwise the bone will resorbe again.

Orthodontist might extract deciduous and supernumerary teeth to provide sufficient attached gingiva.

Treat caries and pathology The orthodontist is often required to expand the maxillary arch prior to alveolar bone grafting, usually with a fixed expander such as a tri- or quad-helix. This expansion maximizes the size of the bony defect, improves the maxillary arch form and creates access for the surgeon to place the graft during surgery.

Then the expander should be replaced with a stabilising transpalatal arch with palatal extensions prior to surgery to facilitate surgical access. Bilateral cleft cases require a stabilising arch wire to secure the pre-maxilla, at least 19*25 SS.

Transpaltal arches should remain for upto 3 months after surgery for stabilisation.

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Care should be taken when aligning the incisors, as often the bone covering the roots of the teeth is very thin. Often the aim then is to accept the mesio-distal tip and rotations present in the upper incisors. Therefore when placing the brackets it is wise to accept the inclination of these teeth rather than try to upright them and moves the roots of the teeth out of the bone and into the cleft space. After the bone graft the brackets can be replaced and the roots moved into the correct position.
The main aims of this procedure to:

1. 2. 3. 4. 5. 6. 7.

Aims to stabilize maxillary segments Facilitate any prosthetic restoration Allow spontaneous eruption of teeth into the cleft area Enable orthodontic tooth movement through the cleft site, Improve bony support for the alar base. Eliminate any mucosal recesses liable to cause food retention. Improve nasal symmetry where there is skeletal dysplasia of the area lateral to the nostril.
Surgical technique of ABG.

1. Incision 2. After closure of the nasal surface, 3. Cancellous bone is harvested from donor sites, The best source of bone for grafting for the alveolar cleft defect is the iliac crest, The rib, the cranium, tibia and the mandible or artificial bone graft have also been used. 4. cortical bone is not preferred because of the reduce vasculaity and high risk of necrosis. 5. Additional bone is placed under the ala and the nose on the cleft side to provide nasal symmetry. 6. The covering flaps are then closed.
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7. A protective palatal splint or orthodontic arch wire is sometimes used for further stabilization, 8. Modified flaps may be needed to close residual palatal fistulae defects. 9. success rate when graft placed prior to eruption of canine 90%. 72% after or during eruption of canine. 10. Success of UCLP=BCLP if adequate stabilisation of premaxilla. 11. then it is usually possible to proceed with orthodontic movement of teeth in the grafted
Postoperative assessment
1. 2. 3.

General assessment After 6 weeks to check infection After 4-6 months Kindelean score one year after ABG, Bergland index

The complications

1. Granuloma formation . 2. failure 3. postsurgical problem at donor area 4. Around 15% of the canines will require exposure. 5. External root resorption.
Influencing success

1. Dental development best results when carried out before canine eruption (Bergland et al, 1986; Lee et al, 1995; Kalaaji et al, 1996; Enemark et al, 1997) 2. Donor site: Iliac crest best (LaRossa et al, 1995) although not statistically significant in CSAG study Williams and Sandy, 2003) also tibia, rib, genial and cranial
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3. Pre-operative health of graft site 4. Post-operative complications 5. Socioeconomic status and ethnic group 6. Surgical procedure + more experience = better results 7. Extraction of teeth at surgery (not statistically significant in CSAG (Williams and Sandy, 2003) 8. Surgeon specialty (OMFS better than Plastic surgeon) not statistically significant (Williams and Sandy, 2003) 9. Bone volume weigh alveolar bone (Kamakura et al, 2003) 10. Complete closure of fistulae 11. Impaction of canines

11-15 Years of age


Pharyngoplasty

Pharygoplasty may be undertaken at 11-15 years to improve velo-pharyngeal competence, if not already undertaken at an earlier age.

VPI may become a greater problem in the adolescent as lymphoid tissue shrinks effectively increasing the distance the scarred soft palate needs to breach to create a seal.
Orthodontics

Conventional orthodontic treatment if the malocclusion is simple with or without EOA

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18+ Years of age


1. Lees Records 2. Orthognathic surgery

There is usually a need for pre-surgical orthodontics. due to risk of worsening VPI and due to previous surgical scarring, the Large jaw discrepancies of 10mms and above may also require a mandibular setback

a modified maxillary Le fort 1 advancement or Converse Wake Procedure (that move the maxilla without influencing the position of the palate) is used with careful attention paid to the mobilisation of the maxilla.

Use Distraction osteogenesis as alternative Use Horseshoe osteotomy as alternative Severe maxillary restriction may require Surgically assisted RME and 2 or 3 piece Le fort 1 osteotomies

Any expansion gained should be permanently retained. (Proffit and White 1990)
3. Secondary plastic procedures

Such as nose and lip revision. These are best undertaken after growth, since growth can detrimentally affect earlier revisions.

Terminology
Velopharyngeal impairment is a generic term indicating that the patient is unable to

induce sufficient contact between the velum and the posterior and lateral pharyngeal walls
Velopharyngeal insufficiency is a form of velopharyngeal impairment caused by a

soft palate whose functional length is insufficient.


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Velopharyngeal incompetenceis a form of velopharyngeal impairment caused by

neuromuscular impairment . Hypernasality is a resonance phenomenon that occurs when sound is inappropriately generated in the nasal cavity.

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